Published On: 11/14/2022
Duration: 14 minutes, 44 seconds
Referenced Article: “Supervised Drug Consumption Sites,” The Carlat Addiction Psychiatry Report, July 2022
Noah Capurso, MD, MHS, and Chris Clayton, MD, have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity
Dr. Capurso: Supervised Consumption Sites are clinical settings where patients can use drugs safely. Clients are supplied with sterile equipment and clinics are staffed by medical professionals who can respond to medical emergencies, including overdose. Once controversial, research clearly shows the benefit of these sites. Previously operating only underground, the first officially sanctioned sites have started opening in the United States. In this podcast, we will review the purpose of these sites, the evidence behind them, and how to discuss them with your patients.
Welcome to The Carlat Psychiatry Podcast.
This is a special episode from the addiction treatment team.
I’m Dr. Noah Capurso, The Editor-in-Chief of The Carlat Addiction Treatment Report and an assistant professor of psychiatry at the Yale University School of Medicine.
Dr. Clayton: And I'm Dr. Christopher Clayton, chief resident in psychiatry at NYU School of Medicine.
So let's start off by discussing what supervised drug consumption sites are, and a little bit about the evidence behind them. So a supervised consumption site, or SCS, is a clinical setting with trained medical staff where clients come to use drugs, most commonly intravenous opioids.
Clients bring their own drugs. The clinic or the supervised consumption site does not provide any substances and the clinic instead provides sterile injection equipment in order to decrease the transmission of blood-borne infections, as well as a safe and secure place to inject drugs.
Drugs are usually used in cubicles, which provide some semblance of privacy while allowing for staff to monitor for signs of overdose. And if an overdose does occur, trained staff members carrying the naloxone can quickly treat the patient and, if necessary, arrange for transportation to an emergency room. The site usually includes other services as well, like food, clothing, mental health counseling, peer specialists, sometimes some basic medical care for skin infections, things like that, and most importantly, a hub for referral to addiction treatment when clients are ready.
Dr. Capurso: Can you talk about how supervised drug consumption sites fit into the framework of harm reduction?
Dr. Clayton: Yeah, absolutely. So supervised consumption sites fit right into the framework of harm reduction. This is really because they prioritize the survival and the health of patients over complete abstinence from drugs. There's a lot of different harm reduction services available in the US, those include things like needle exchanges or distribution of naloxone, which has become pretty common, but until recently, no supervised consumption sites could open, and this is actually because of a federal law that's colloquially known as the Crack House statute.
So this law was on the books for decades, and really, the legal landscape changed in 2019 when a federal judge ruled in favor of a Philadelphia not-for-profit that was opening a supervised consumption site in their city. So they ruled that basically because the mission of the supervised consumption site was a public health one, that the statute that prevented kind of communal drug use in a setting didn't apply. This really opened the opportunity for supervised consumption sites to get developed in the US and open.
Unfortunately, the Philadelphia one wasn't successful in opening. They kind of ran into more community roadblocks, but New York really opened the gates in November of 2021 with the first site, and they are up to two in the city now.
Dr. Capurso: So what is the evidence say? Are these sites beneficial, or do they lead to increased drug use?
Dr. Clayton: So that's a really great question. There's a lot of excellent evidence to support the establishment of SDS, and there's a lot of evidence to counter that common concern that they might actually lead to increased drug use. So it's important to recognize that this evidence comes from 2 main sites, one in Vancouver, Canada called Insight, and the other in Sydney, Australia and that one is called Uniting MSIC or Medically Supervised Injection Center. So these two sites have been in operation for decades and have really compiled the bulk of the data to support SCS, and the data are really impressive.
So they've shown that there is clearly a reduction in overdose related harms when compared to neighborhoods that have similar demographic makeups that don't have SCSs available. So what this shows is that there is a reduced number of hospitalizations for overdoses in those areas and a reduced number of overdose deaths. And incredibly, there's actually been no overdose deaths recorded in any supervised consumption site since these kind of came onto the scene in the 80s in Europe.
And considering how lethal opioid injection can be, safe especially with the introduction of fentanyl in more recent years, this is a really incredible finding.
The other side of things is the evidence for whether or not SCS encourage people to use drugs more or actually connect people to care, and what we see is that consistently they connect people to care. So attendance within SCSs is associated with enrollment in addiction treatment and ultimately cessation of injection drug use. And additionally, it's associated with better care of physical conditions associated with injection. So, clients who were hospitalized with skin infections from injecting drugs who were referred from an SCS had shorter lengths of stay than those who kind of self presented. So this suggests that are detecting people with kind of skin infections, common health problems from drug use earlier and getting them connected to treatment.
So overall, we see that they're reducing overdose deaths, reducing overdose hospitalizations, connecting people to care earlier for common problems that an injection drug user might face, and connecting people to treatment, which is really the end goal.
Dr. Capurso: Historically, there has been resistance to SCS by those living in the community. There is a bit of a “not in my backyard” phenomenon. The worry is that the clinic will be bad for the surrounding neighborhood. What does the data show there?
Dr. Clayton: So that's absolutely been a concern, and it's one that's really not borne out by the data. So surprisingly, studies show that the presence of an SCS does not lead to any increased crime. And this is a common concern with the establishment of these SCS and it's been a barrier to the establishment of similar centers throughout the country or in international settings.So what we end up seeing is that ultimately in these studies out of Vancouver and Sydney, the people in the surrounding neighborhoods tend to view these clinics as a favorable contribution to the neighborhood.
And there's been a lot of hypotheses as to why, but what kind of comes up is that they provide people a safe space to be while they're using drugs, and to dispose of different instruments used for injecting.So dispose of needles appropriately and that reduces litter in the neighborhoods. It reduces loitering or the presence of people who are intoxicated on the streets and this was seen as very favorable from the neighborhood.And then in terms of looking at drug related risk behaviors, they ended up showing in a lot of these studies that there was a reduction in needle sharing, needle reuse, outdoor injections, rushed injections, improper disposal of syringes.
So what this also shows is that clients find this as a safe area and they find it as a beneficial resource for them. It's a place that they feel comfortable, and it kind of reduces a lot of the hazards that come with a life surrounded by injection drug use. And then lastly, openings of SCSs in these cities did not impact population rates of relapse or initiation into injection drug use at all. So we kind of again come back to this reiterated finding that these centers don't seem to encourage drug use.They seem to really target people who are highly at risk and give them important resources to recover.
Dr. Capurso: Ok so overall it seems like SCS are promising. They reduce overdose deaths and help connect clients to treatment when they’re ready for it. And the ancillary services are helpful as well. And of course, you discussed the positive impact that a clinic can have on the surrounding area. But these clinics have to be staffed. Is it cost effective?
Dr. Clayton: Yeah, absolutely. So if you're thinking about monetary costs of an intervention like this, you have to take into consideration the expensive adverse outcomes that you're trying to prevent.
So that includes death from opiates, which is a huge cost to someone's life, as well as hospital care, which is really expensive. That includes ambulance rides, emergency department visits, extended stays for IV antibiotics. So what we see time and time again is that preventive care like this tends to be the most cost effective approach in the long term and you can think of SCS as falling under that same umbrella as preventive care. So there's been a few studies about costs that have kind of run simulations and estimated this. And when you compare the cost of perhaps something like treatment of HIV or viral hepatitis contracted from drug use or the cost of an overdose death or hospitalization, it's significantly higher than the cost of staffing one of these centers. Economic analyses have estimated that the cost of an SCS is on par with things like methadone treatment, which are widespread, as well as buprenorphine treatment. And importantly, there we're capturing a different population than those two resources. Methadone and buprenorphine treatment are people who are engaged in treatment, interested in abstinence. On the flip side, we're hopefully capturing this population who's pre contemplated, they're not ready to engage in that treatment yet and reducing the amount of health care expenditure associated with them. 17:06
Dr. Capurso: How should providers discuss these sites with their patients? And what types of patients should providers keep an eye out for when determining who to refer?
Dr. Clayton: So as we were discussing, the people who are most likely to benefit from a referral to an SCS are those who are not ready to engage in formal addiction treatment. They're not ready to pursue abstinence as part of their recovery. So you want to frame this conversation in terms of harm reduction and be sure to understand or make sure that your patients understand that an SCS is not a substitute for these other evidence based treatments like methadone, like buprenorphine, but instead something for someone who's not yet ready to engage in that.
And you could say something along the lines of, you know, the safest option is to start treatment with a medication like buprenorphine or methadone and see if this option is abstinence. We understand that that's difficult to achieve and while you're continuing to use drugs, there's ways to make that safer. One of those ways is taking it at a supervised consumption site. It ensures that you have access to sterile supplies, that you're safe while you're under the influence, and if you need medical attention, if you are experiencing an overdose that it's there, it's available.
And then the staff there are also ready to refer you for treatment if you're interested in the future.
But even if your patient is engaged in treatment, it's still worth discussing SCS with them so that patients may be able to pass that information along to someone they know, someone they used to use with, and they also might be able to consider it for themselves in the case of relapse. You can say something like using drugs after a period of abstinence can be really dangerous, and so you have less tolerance and you'd be at higher risk for overdose.So if you ever found yourself tempted to use drugs again, I would recommend that it would be safer in a setting like a supervised consumption site.
Dr. Capurso: And what if there aren’t any available locally? Patients still might ask about them.
Dr. Clayton: Yeah, this is true. They're not widespread at this point in the US and so for those of you who are not in New York City, keep an eye out because these are likely coming to a city near you. The centers that have started in New York City have had a really good response and so with that trial under the belt of these organizations, it's likely that these types of centers will begin appearing in other areas. But even if they aren't accessible to you right now, you can use a similar discussion as an opportunity to reinforce these key principles of harm reduction and emphasize that they can be lifesaving outside of a supervised consumption site. So you could say something like, you know, we don't have SCS in our area yet but you can use some of these same principles to keep yourself safer when you're using drugs. For example, using clean needles reduces your risk of infections like hepatitis or HIV. Using with other people around is going to help keep you safe from overdose, even with just someone on the phone who could call emergency services if you stop talking.
And then we really want to be thinking about distributing the naloxone to any patients who we think are at risk. And I would encourage people to include patients who are using any type of substance who might be in an environment with someone who's using an opiate, or might be injecting other drugs that could be tainted with opioid products. So naloxone as widespread as possible to help people feel empowered to treat themselves or treat other people in the case of overdose.
Dr. Capurso: That’s great advice. Also, remember to stay up to date about SCS developments in your area by contacting your state public health department and local harm reduction organizations, such as needle exchange programs. And you can learn about the latest evidence via the National Harm Reduction Coalition at https://harmreduction.org/.
Dr. Clayton: The newsletter clinical update is available for subscribers to read in The Carlat Addiction Treatment Report. Hopefully, people will check it out. Subscribers get print issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits.
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Dr. Capurso: And don’t forget, you can now earn CME credits for listening to our podcasts. Just click this link to access the CME post-test for this episode.
As always, thanks for listening and have a great day!